The Process of Developing Best Practice Guidelines for Nurses in Ontario: Risk Assessment and Prevention of Pressure Ulcers

  • Wed, 9/3/08 - 10:25am
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Author(s): 
Frances E. MacLeod, RN, MScN; Margaret B. Harrison, RN, PhD; and Ian D. Graham, PhD

I n order to meet consumer expectations for quality care, healthcare professionals are required to apply knowledge and expertise that reflects current best practice.1 The provision of healthcare services in Canada is mandated and funded by the provinces and territories; therefore, healthcare policy and professional practice is largely overseen at this level. The Registered Nurses Association of Ontario (RNAO), in cooperation with the Ontario Ministry of Health and Long Term Care (MOH/LTC), has played a lead role in this area. Following a major review of nursing in Ontario,2 the RNAO and the MOH/LTC established an initiative to assist nurses with complex healthcare situations across the continuum of healthcare. The main goal was to ensure that nursing practice in Ontario would be supported by current clinical evidence. In an initiative known as the Nursing Best Practice Guidelines (NBPG) Project, the RNAO, with funding from the MOH/LTC, convened selected panels to develop guidelines for best practice and through a province-wide competition, selected pilot implementation sites to evaluate use of the guidelines.

The RNAO project was specifically mandated to review, update, and synthesize recommendations from all good quality international guidelines for application in Ontario. The Panel was concerned that the 1992 Agency for Health Care Policy and Research (AHCPR)3 guideline had not been updated since its release. However, on conclusion of the process, the AHCPR guideline on pressure ulcer prevention remained valid. A recent review showed it to be one of the few AHCPR guidelines that remained valid as of 2000.4 If the panel had not reviewed recent guidelines and evidence, the process would have been less credible to Ontario practitioners. The background and process used to develop the RNAO practice guidelines for nurses, using the example of one panel's work in developing best practice guidelines for risk assessment and prevention of pressure ulcers, is described.

Background

Clinical practice guidelines are intended to offer concise instructions on how to provide healthcare services.5 The most important benefit of clinical practice guidelines is their potential to improve the process of care provided by professionals as well as patient health outcomes.6,7 However, their benefits are contingent on 1) a guideline development process that is methodologically rigorous, 2) content that incorporates the best evidence available, and 3) demonstrated successful implementation of the resulting guideline.8,9

Increasingly, professional associations such as the RNAO recognize that the development of evidence-based guidelines requires a systematic and structured process. The process gains validity when both formal and informal consensus development occurs along with a systematic review and appraisal of the literature.10 This project incorporated a number of positive features of guideline development and appraisal processes.11-15 In addition, continuous RNAO support for literature searches, meetings, teleconferences, and secretarial assistance helped the project succeed.

References: 

1. College of Nurses of Ontario. Reference Guide to Standards of Practice for Nurses in Ontario. College Communique.1998;23(3).
2. Government of Ontario Ministry of Health and Long Term Care Report of the Nursing Task Force. Good Nursing, Good Health: An Investment in the 21st Century. Queens Printer; 2000. Available at : http://www.go.on.ca/health/english/pub/ministry/nursrep99/toc.html.
3. Bergstrom N, Allman RM, Carlson CE, et al. Clinical Practice Guideline Number 3: Pressure Ulcers in Adults: Prediction and Prevention. Rockville, Md.: US Department of Health and Human Services. Public Health Service. Agency for Health Care Policy and Research; 1992. AHCPR Publication 92-0048.
4. Shekelle PG, Ortiz E, Rhodes S, et al. Validity of the Agency for Healthcare Research and Quality clinical practice guidelines: how quickly do guidelines become outdated? JAMA. 2001;286(12):1509-1511.
5. Woolf SH, Grol R, Hutchinson A, Eccles M, Grimshaw J. Potential benefits, limitations, and harms of clinical guidelines. British Medical Journal. 1999;318:527-530.
6. Grimshaw J, Freemantle N, Wallace S, Russell I, Hurwitze B, Watt I, et al. Developing and implementing clinical practice guidelines. Quality Health Care. 1995;4:55-64.
7. Grimshaw J, Russell I. Effect of clinical guidelines on medical practice: a systemic review of rigorous evaluations. Lancet. 1993;242:1317-1322.
8. Worrall G, Chaulk P, Freake D. The effects of clinical practice guidelines on patient outcomes in primary care: a systematic review. Can Med Assoc J. 1997;156:1705-1712.
9. Thomas L, Cullum N, McColl E, Rousseau N, Soutter J, Steen N. Guidelines in professions allied to medicine. Cochrane Library. 1999;3:1-14.
10. van Rijswijk L. Clinical practice guidelines: moving into the 21st century. Ostomy/Wound Management. 1999;44(suppl 1A):47S-53S.
11. Browman GP, Levine MN, Mohide A, Hayward RSA, Pritchard KI, Gafni A, et al. The practice guidelines development cycle: a conceptual tool for practice guidelines development and implementation. J Clin Oncol. 1995;13(2):502-511.
12. American Nurses Association. Utilization of Agency for Health Care Policy and Research (AHCPR) Guidelines. Washington, DC: American Nurses Publishing, 1994.
13. Graham ID, Lorimer K, Harrison MB, Pierscianowski T, for the Leg Ulcer Protocol Task Force, Leg Ulcer Protocol Task Force Working Group et al. Evaluating the quality and content of International Clinical Practice Guidelines for Leg Ulcers: Preparing for Canadian adaptation. Canadian Association of Enterostomal Therapy Journal. 2000;19(3):15-31.
14. Graham ID, Harrison MB, Brouwers M. Evaluating and adapting practice guidelines for local use: a conceptual framework. In: Pickering S, Thompson J (eds). Clinical Governance in Practice. London, UK: Harcourt; In Press.
15. Graham ID, Beardall S, Carter AO, et al. What is the quality of drug therapy clinical practice guidelines in Canada. CMAJ. 2001;165(2):157-181.
16. Registered Nurses Association of Ontario. Advanced clinical fellowships and best practice guidelines projects. Registered Nurse Journal. 2000;12(1):22,26-27.
17. Clinical Resource Efficiency Support Team (CREST). Guidelines for the prevention and management of pressure sores: recommendations for practice. Belfast: CREST Secretariat; 1998.
18. European Pressure Ulcer Advisory Panel. A policy statement on the prevention of pressure ulcers from the European Pressure Ulcer Advisory Panel. British Journal of Nursing. 1998;7(15):888, 890.
19. Effective Health Care. The prevention and treatment of pressure sores: how effective are the measures for scoring people's risk of developing a pressure sore? Effective Health Care Bulletin. York, U.K., NHS Centre for Reviews and Dissemination: University of York; 1995;2(1).
20. Folkedahl BA, Frantz RA, Goode C. In: MG Titler, (ed). Research-based Protocol: Prevention of Pressure Ulcers. The University of Iowa Gerontological Nursing Interventions Research Center; 1997.
21. van Rijswijk L, Braden BJ. Pressure ulcer patient and wound assessment: an AHCPR clinical practice guideline update. Ostomy/Wound Management. 1999;44(suppl 1A):56S-67S.
22. Cluzeau F, Littlejohns P, Grimshaw J, Feder G. Appraisal instrument for clinical guidelines. St.George's Hospital Medical School; 1997. Available at: http://sghms.ac.uk/phs/hceu/.
23. Graham ID, Calder L, Hebert PC, Carter A, Tetroe J. A comparison of clinical practice guideline appraisal instruments. Journal of the International Society for Technology Assessment in Health Care. 2000;16(4):1024-1038.
24. Cluzeau F, Littlejohns P, Grimshaw J, Feder, G, Moran S. Development and application of a generic methodology to assess the quality of clinical guidelines. Int J Qual Health Care. 1999;11:21-28.
25. Cluzeau F, Littlejohns P. Appraising clinical practice guidelines in England and Wales: the development of a methodologic framework and its application to policy. Jt Comm J Qual Improv. 1999;25(10):514-521.
26. Harrison MB, Graham ID. Quality Appraisal of Clinical Practice Guidelines for the Prevention of Pressure Ulcers. Technical Report to the RNAO Wounds Panel. April 28, 2000.
27. Scottish Intercollegiate Guidelines Network (SIGN). The care of patients with chronic leg ulcer: a national clinical guideline. SIGN Secretariat. Edinburgh, UK: Royal College of Physicians and Surgeons; 1998.

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